What India needs to sustain the June 21 vaccination feat

By Dr Rajib Dasgupta

With nearly 8.6 million COVID-19 vaccines administered on 21 June, it was quite a feat! This is double that of the previous high of about 4.3 million doses of 5 April. One hopes this could be the ‘new normal’ and not an ‘uptick’ or a ‘surge’. To temper this with a dose of realism, it will take the next three months to vaccinate the adult population with at least a single dose at about 7.5 million doses daily, and a little over six months with two doses. Optimistic estimates of the national technical leadership have put a capacity of about 12.5 million vaccinations per day which shall lead to a proportionate decline in these numbers of days. These estimates assume an assured supply of about 200 – 220 million doses next month.

The recent ‘State of the Economy’ report of the Reserve Bank of India noted that the speed and scale of vaccination against COVID-19 will shape the path of economic recovery. As the adage goes, vaccines do not save lives, vaccinations do. All vaccination programmes have their share of inequity and hesitancy and the speed and scale of the ongoing campaign shall be shaped by how well and how fast these elements are understood and addressed.

The Union Health Secretary chaired a high-level meeting on 10 June. Low vaccination coverage among Healthcare Workers (HCW) and Frontline Workers (FLW), especially for the second dose for both the priority groups, was reviewed as a “cause of serious concern”. Till that date the national average for the first dose coverage among the HCWs was 82% and that of the second dose was only 56%. For FLWs, the figures were 85% and 47% respectively. Further, states that performed below the national average included those with well-functioning health service systems and include Andhra Pradesh, Karnataka, Maharashtra, Telangana, Tamil Nadu and Punjab. As is well known, vaccination for these prioritised groups started on 16 January and the full schedule was being completed at that time in 4-8 weeks.

Those aged more than 60 years and 45 plus with comorbidities began to get vaccinated from March 1. The progress in the next four months (till first week of June): about 43 per cent in the 60-plus category had received the first dose and 37 per cent in the 45-above age group. The slow progress among those with the highest risks — in terms of occupational, age and co-morbidity categories – in all likelihood indicate a mix of both hesitancy and inequity.

The recently released survey report by the National Campaign Committee for Central Legislation of Construction Labour found that only 21.3% of Delhi’s informal workers had received their first dose. Contrast this with the fact that close to half of Delhi’s population over the age of 45 has got at least one dose of the vaccine. A recent analysis also found that 114 of India’s aspirational (least developed) districts received the same number of doses that were administered across nine major cities whose combined population account for half the population of these aspirational districts. Data from the Co-Win website indicate three key messages: the second dose has remained stagnant at about 0.4 million daily though the cumulative numbers of the first dose is steadily rising; coverage among the 60-plus and 45-plus age groups declined steadily from its highest level in mid-April and plateaued since end-May (though significant numbers are yet to be immunised); except Chhattisgarh and Kerala, all state immunised more women than men and in the aggregate 17% more men are partly or fully vaccinated than women.

Vaccine hesitancy is a behavioural phenomenon that is vaccine and context specific and measured against an expectation of reaching a specific vaccination coverage goal; given that immunisation services are available. It entails asset of layered challenges: complacency, confidence and convenience. Vaccine confidence encompasses trust in the effectiveness and safety of the vaccine; the system that delivers, including the reliability and competence of the health services and professionals and the perceived motivations of policy-makers making decisions on the vaccine. Vaccination complacency exists where perceived risks of the disease in question are low and vaccination is not deemed a necessary preventive action. Vaccination convenience is a significant factor that entails physical availability, affordability and willingness-to-pay (for those who would not be eligible for or would not like to avail of the government programme) for the vaccine as well as the ability to understand (language and health literacy) and appeal of the vaccine and the real or perceived quality of service.

Central and state governments have taken a series of measures to “bust vaccination myths”. Communication strategies are critical for tracking, negotiating and shaping perceptions around the vaccines and the programme. Communication strategies and responses need to be shaped around four key themes: product development (for these new vaccines), prioritisation strategies, programme rollout activities, and AEFI (Adverse Effects Following Immunisation) and AESI (Adverse Effects of Special Interest). At this point, both vaccine optimism and vaccine scepticism co-exist. These require proactive sharing of information to build trust and confidence as well as real-time responses as new forms of hesitancy emerge.

The combination of enthusiasm and service delivery noted yesterday is a significant development. The fact that most of this is among the 18-44 years age group is also a welcome signal towards opening up the economic and educational sectors. The ongoing state initiatives to cater to hard-to-reach and underserved areas should continue to be supported and refined. Supply-side challenges are well known; adequate information on production capacities and supply commitments to the central government as well as allocation strategies to the states are critical determinants. India has a proven capacity to conduct large scale immunisation campaigns; among other things, it will require good micro-planning in tandem with allocation commitments.

(The author is Chairperson at the Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi. He is also a member of the National AEFI (Adverse Effects Following Immunisation) Committee. Views are personal.)